Neighborhood Health Plan of Rhode Island Medicaid Drug Formulary - Outpatient Pharmacy Coverage Criteria
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Defines the outpatient pharmacy formulary, coverage rules, prior authorization, step therapy, and exception processes for Neighborhood Health Plan of Rhode Island Medicaid members and guides prescribers, pharmacists, and members on use and appeals.
No material clinical or coverage changes in this revision.
Coverage Criteria
General Coverage Provisions
Covered when ALL of the following general provisions are met
Replacement of lost or stolen medications considered case-by-case; infertility treatments not covered.
Non-formulary medications are subject to quantity limitations as specified on Neighborhood's website.
State and federal requirements may affect formulary coverage.
Non-Formulary Exception Criteria
Non-formulary and restricted drug coverage
Requests are reviewed by Neighborhood pharmacy and medical staff; see Adverse Determination section for denials process.
PA requests may be faxed to 1-866-423-0945 or phoned to Neighborhood Pharmacy Department at 1-401-427-8200.
Provider must document why required formulary alternatives are unsuitable or have failed.
The formulary does not provide information about all individual member coverage limitations; it applies only to outpatient drugs and does not apply to inpatient medications. Drugs not listed in the formulary are not covered. Some OTC products may be covered only when a written prescription is provided. Cosmetic products, infertility treatments, and replacement of lost or stolen medications (evaluated case-by-case) are excluded. Unless otherwise stated, dispensed quantities are limited to one month's supply. Formulary coverage is subject to state and federal requirements, and non-formulary medications may be subject to quantity limitations referenced on Neighborhood's website.
Any drug product or any use of an existing product that the Neighborhood P&T Committee determines to be experimental or an experimental/off‑label use is not covered. The Committee makes this determination based on current medical literature and evidence; such determinations result in exclusion from formulary coverage.
Provider Actions and Prior Authorization
Prior Authorization Required
Drugs listed with 'PA' on the Formulary require Prior Authorization before coverage will be approved when a member presents a prescription at a network pharmacy. To request Prior Authorization, a prescriber or the prescriber's representative must either: 1) fax a completed Prior Authorization Request to the Neighborhood Pharmacy Department at 1-866-423-0945, or 2) contact the Neighborhood Pharmacy Department pharmacist at 1-401-427-8200 and provide all necessary clinical information. Each request is reviewed for individual patient need and against criteria approved by the Neighborhood P&T Committee.
- Fax PA requests to 1-866-423-0945
- Phone Neighborhood Pharmacy Dept at 1-401-427-8200
- PA review based on patient need and P&T-approved criteria
Required Information for Exceptions and Prior Authorization
When requesting a Prior Authorization or an exception to formulary requirements (including Step Therapy or coverage of a non-formulary drug), prescribers must submit clinical justification and supporting documentation. Appropriate information includes the clinical rationale that formulary products are contraindicated, prior trials and failures of formulary or related agents, why formulary choices are not suited to the patient’s care needs, or evidence that use of a formulary drug would provoke or worsen an underlying condition. Neighborhood pharmacy and medical staff will evaluate submissions; the prescriber may be contacted for additional information.
- Document contraindications to formulary agents
- Provide records of failed trials of formulary/related drugs
- Explain why formulary options are unsuitable for the patient’s clinical needs
- Detail safety concerns or risk of provoking underlying conditions
Step Therapy and Exceptions
Drugs listed with 'ST' on the Formulary are subject to Step Therapy: the member must have tried specified formulary alternatives prior to coverage of the requested medication. If required formulary alternatives are inappropriate or cannot be tolerated, the provider may request a Step Therapy exception by submitting clinical justification and supporting documentation as described above. Exception requests will be reviewed by Neighborhood pharmacy and medical staff and considered against P&T‑approved criteria.
- Step Therapy requires documented trials of specified formulary alternatives
- Submit exception requests with clinical rationale if alternatives are inappropriate or not tolerated
- Exception review follows P&T‑approved criteria
Denials, Notification, and Appeals
If a request for Prior Authorization or a formulary exception does not meet criteria, Neighborhood will provide the prescribing provider with the rationale and formulary alternatives. The prescriber may be referred to the Neighborhood Medical Director or Physician Reviewer for further discussion and final determination of medical necessity. In the event of a denial, the Medical Director or Physician Reviewer will: discuss the reason for denial with the prescriber, provide written notice to both prescriber and member documenting the decision and applicable guidelines, and outline the appeals process. Members may also contact Customer Service to register an inquiry or complaint and be informed of appeal rights.
- Rationale and alternatives provided to prescriber when criteria not met
- Prescriber may discuss the case with Medical Director or Physician Reviewer
- Denial letters to prescriber and member will document reasons, guidelines, and appeal instructions
- Members can contact Customer Service to file inquiries/complaints and learn appeal rights
Definitions
Step Therapy Requirements
| Requirement | Details | Provider action |
|---|---|---|
| Step Therapy requirement | ||
| Members must try specified formulary alternatives prior to coverage of a drug labeled 'ST'. | ||
| If formulary alternatives are inappropriate or cannot be taken, the provider may request an exception to Step Therapy (submit clinical justification). |
Quantity Limits
Background
The formulary is maintained and reviewed by the Neighborhood P&T Committee, which evaluates drugs using current medical literature and considers safety, efficacy, effectiveness, comparative benefits, cost-effectiveness, duplication, and usage restrictions. The Committee meets regularly (quarterly) to add or review formulary agents and to determine whether products or specific uses are experimental and therefore excluded from coverage.
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